A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? (Select all that apply.)
Assess for neck vein distention
Monitor for postural hypotension
Assess blood glucose level
Monitor for an irregular heart rate
Weigh the client daily
Correct Answer : A,C,D,E
A. Assess for neck vein distention: Neck vein distention can occur in Cushing's syndrome due to fluid retention and hypertension. It is an important sign to monitor as it can indicate complications like heart failure.
B. Monitor for postural hypotension: Clients with Cushing's syndrome typically have hypertension rather than hypotension. Therefore, postural hypotension is not a common issue to monitor for in these patients.
C. Assess blood glucose level: Hyperglycemia is common in Cushing's syndrome due to increased cortisol levels, which promote glucose production and reduce glucose uptake by cells. Monitoring blood glucose is essential to manage this condition.
D. Monitor for an irregular heart rate: Cushing's syndrome can cause electrolyte imbalances (like hypokalemia), which may lead to cardiac arrhythmias, so monitoring for an irregular heart rate is important.
E. Weigh the client daily: Daily weight monitoring helps track fluid retention, which is common in Cushing's syndrome due to cortisol-induced fluid retention. This can help in managing the client’s fluid status and detecting worsening of symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Your blood sugar is very unstable." While high HbA1C levels can indicate poor glucose control, they do not specifically indicate instability in blood sugar levels (i.e., frequent fluctuations between high and low levels). HbA1C does not capture short-term variations in blood glucose; it only provides an average over a few months.
B. "Your blood sugar is too high after meals." Although postprandial (after-meal) glucose levels contribute to overall blood glucose levels, HbA1C measures the average blood glucose level over several months and is not specific to postprandial glucose levels. A high HbA1C suggests elevated glucose levels overall, not just after meals.
C. "Your average blood sugar is high." HbA1C measures the average blood sugar level over an extended period, typically 2-3 months. A result of 9% indicates that the client's average blood glucose levels have been consistently high, suggesting poor long-term glucose control. This is a precise and appropriate statement reflecting the meaning of the HbA1C result.
D. "You have many dangerously low blood sugar levels." A high HbA1C indicates elevated blood glucose levels over time, not low levels. Low blood sugar levels (hypoglycemia) would not contribute to a high HbA1C. In fact, frequent hypoglycemia would more likely result in a lower HbA1C, not a higher one.
Correct Answer is A
Explanation
A. Genetics: Genetics is a non-modifiable risk factor for stroke, meaning it cannot be changed or controlled. A family history of stroke increases an individual's risk due to inherited traits or predispositions.
B. Obesity: Obesity is a modifiable risk factor. Individuals can reduce their risk through diet, exercise, and other lifestyle changes.
C. History of smoking: Smoking is a modifiable risk factor, as individuals can quit smoking to reduce their risk of stroke.
D. History of hypertension: Hypertension is also a modifiable risk factor, as it can be managed and controlled with medication and lifestyle changes.
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